Many seniors prefer to remain in their own homes with the help of relatives, neighbors and other informal caregivers. Research shows such informal care can help avoid hospitalizations. (Photo by Kathy Quirk)

Up to 30 percent of elderly patients released from the hospital into home healthcare end up back in the hospital within 60 days, most within 20 days.

A University of Wisconsin-Milwaukee nursing researcher is studying how informal caregivers – family, friends and others – can help reduce those rehospitalizations.

“Most of these rehospitalizations are preventable,” says Hong Tao, an assistant professor in the College of Nursing. “It’s a high cost for Medicare; it’s expensive for the home health care agencies; and, it’s a concern for the patients and their families.” Estimates are that these readmissions account for $15 billion in Medicare spending.

Hong Tao

Tao’s research, recently published in the journal, “Advances in Nursing Science,” looks at the social and environmental factors that affect rehospitalization risk in home healthcare patients. The article has received widespread attention after being republished in Wolters Kluwer.

While numerous studies have been done on caregiver stress, not many have looked at the role family members or other informal caregivers play in working with government-funded home health services, says Tao of the research she and her colleagues did.
Understanding the role of these social environmental factors is important in setting policies on reimbursement strategies, preventing hospital readmission and assuring patients of quality care, she notes.Her study, which was done two years ago, involved 1268 Medicare patients, ages 65-99, receiving home health care in Massachusetts. Her interest in the subject grew out of her own experiences during an internship with a home health agency serving 30 towns. “From that experience, I recognized that rehospitalization was a big concern.”

Routine, required Medicare assessments done when patients entered the home health program provided the data needed for the study. These assessments included information on such factors as whether the patient lived alone or with others, if they had a primary informal caregiver and the type and frequency of informal care provided.

Using this data, Tao was able to look at the “self-care” deficit – the difference between the patient’s ability to care for themselves with the help of informal caregivers and their clinical status. Social environmental factors contributed to the risk of repeated hospitalization by altering the balance between the patient’s need for and ability to care for themselves. The greater this self-care deficit, the more likely the patient was to end up back in the hospital. The study also found that certain health issues, like obesity or loss of intellectual ability also impacted the patient’s clinical status and ability to care for themselves.

While ongoing informal caregiver support was linked to fewer readmissions, Tao’s study also found that elderly people who lived alone had a lower rate of readmissions. While this would seem to contradict the need for informal caregiver support, it could just mean that those seniors who chose to live alone were better able and more determined to function independently, notes Tao.

Estimates are that hospital readmissions of the elderly account for $15 billion in Medicare spending.

While more and broader studies are needed, she says, the aim of her research is to provide scientific evidence that will help home healthcare providers identify patients who are at high risk of returning to the hospital and provide those patients with the support they need.

Tao is also working on an intervention called “The Track and Trigger,” which uses mobile technology to allow informal caregivers and home health care visiting nurses to communicate quickly about certain specific events that might trigger the need for further action.

Another goal of her work is to inform policymakers and regulators about the key role that informal caregivers play, which might in the long run change the way home health services are delivered and reimbursed, she says.

“Informal caregivers are part of the solution in preventing unnecessary hospitalizations and more attention needs to be given to how these caregivers are supported in their roles.”

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